Geriatric Nursing 37 (2016) 434e439

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Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

Infusion treatments and deep brain stimulation in Parkinson’s

Disease: The role of nursing
Anna De Rosa, MD, PhD a, *, Alessandro Tessitore, MD, PhD b, Leonilda Bilo, MD a,
Silvio Peluso, MD a, Giuseppe De Michele, MD a
a
Department of Neurosciences and Reproductive and Odontostomatological Sciences, Federico II University, via Pansini 5, 80131 Naples, Italy
b
Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Naples, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Parkinson’s Disease (PD) represents one of the most common neurodegenerative disorders in the elderly.
Received 7 March 2016 PD is caused by a loss of dopaminergic cells in the substantia nigra pars compacta. The motor cardinal
Received in revised form signs include a resting tremor, bradykinesia, rigidity and postural reflex impairment. Although levodopa
9 June 2016
represents the gold standard also in the advanced stage of the disease, over the years most patients
Accepted 13 June 2016
Available online 18 July 2016
develop disabling motor fluctuations, dyskinesias, and non-motor complications, which are difficult to
manage. At this stage, more complex treatment approaches, such as infusion therapies (subcutaneous
apomorphine and intraduodenal levodopa) and deep brain stimulation of the subthalamic nucleus or the
Keywords:
Parkinson’s Disease
globus pallidus internus should be considered. All three procedures require careful selection and good
Advanced treatment compliance of candidate patients. In particular, infusional therapies need adequate training both of
Nursing caregivers and nursing staff in order to assist clinicians in the management of patients in the complicated
Deep brain stimulation stages of disease.
Ó 2016 Elsevier Inc. All rights reserved.

Introduction including autonomic dysfunction, gastrointestinal disorders (droo-

Parkinson’s Disease (PD), the second most common neurode-
generative disorder after Alzheimer’s Disease, is a progressive
condition characterized by dopaminergic neurons degeneration in
the substantia nigra pars compacta of the midbrain and the pres-
ence in the brainstem and the cortex of Lewy bodies (LB), cyto-
plasmic inclusions mainly composed of a-synuclein fibrils.1 The
mean age at onset is 60 years. The prevalence of PD in industrialized
countries is generally estimated at 0.3% of the entire population and
about 1% in people over 60 years of age.2 The incidence is age-
related, raising from 17.4 in 100,000 person-years between 50
and 59 years of age to 93.1 in 100,000 between 70 and 79 years.1
Men are affected 1.5 times more frequently than women, but
some studies do not confirm a significant gender-related difference
in the prevalence of the disease.2
The main clinical feature of PD is a progressive motor impair-
ment, typically asymmetric at onset and characterized by slowness
of movement (bradykinesia), rest tremor, muscle rigidity and
postural instability.1 Most patients also show non-motor features,
The authors have no conflict of interest to report.
* Corresponding author. Tel.: þ39 081 7464348; fax: þ39 081 5463663.
E-mail address: anna.derosa1@unina.it (A. De Rosa).
ling, dysphagia, constipation), dementia, psychiatric disturbances,
sensory symptoms, and sleep disturbances.3 A prolonged positive
response to levodopa treatment supports the diagnosis and is
useful to differentiate PD from other types of Parkinsonism.1
Levodopa represents the gold standard of PD treatment and
remains the most effective drug even in the advanced stages of the
disease. However, over time motor fluctuations and dyskinesias
may develop, appearing in about 40% of patients after 4e6 years of
treatment.4 The motor fluctuations and dyskinesias depend on
drug dose, clinical severity and disease duration, and often result
refractory to the traditional non-invasive oral treatment.5 There-
fore, new therapeutic modalities have been developed for the
advanced stages of the disease, such as Deep Brain Stimulation
(DBS), Continuous Subcutaneous Apomorphine Infusion (CSAI) and
Levodopa-Carbidopa Intestinal Gel (LCIG), which allow a minimi-
zation of motor complications through a more constant stimulation
of the striatal dopamine receptors, in an attempt to mimic the
normal physiological condition. All three procedures should be
performed according to strict inclusion and exclusion criteria, and
require a careful selection of candidate patients and accurate
monitoring of the possible side effects.
The aim of this review is to focus on these complex therapies,
highlighting implementation rules, effectiveness, indications, con-
traindications (Table 1), side effects, complications, the costs of the

0197-4572/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2016.06.012
 A. De Rosa et al. / Geriatric Nursing 37 (2016) 434e439 435

Table 1 To date, there is evidence that stimulation of both STN and GPi
Indications and contraindications of deep brain stimulation (DBS), continuous DBS improves motor function without any significant differences,
subcutaneous apomorphine infusion (CSAI) and levodopa/carbidopa intestinal gel
(LCIG) infusion.
even if STN stimulation allows a significant dopaminergic
medication reduction, which is useful in patients who present
DBS CSAI LCIG infusion severe dyskinesias, but, on the other hand, it leads to a faster
Indications cognitive decline.10,11 Several randomized controlled clinical tri-
“On-off” fluctuations, “off” state Yes Yes Yes
als showed that STN-DBS was able to control motor symptoms
Dyskinesias Yes Yes Yes
L-dopa resistant axial signs No Yes/No Yes/No and complications, and also improved the self-reported quality of
Contraindications life better than the best conventional treatment up to 5e6 years
Age >75 years Yes Yes No after the electrodes implantation.12 Until now, few studies have
Mild-moderate dementia Yes Yes/No No investigated the long-term efficacy and safety of STN-DBS.
Severe dementia Yes Yes Yes
Psychosis Yes Yes No
Recently, an 11 year follow-up checked the STN-DBS long-term
Severe depression Yes No No outcome in 26 PD patients.13 Up to the latest visit, the motor
Orthostatic hypotension No Yes No complications still appeared well controlled as compared to
Severe systemic disease Yes Yes Yes/No the baseline assessment. The dyskinesias showed an 84.6%
Severe brain atrophy and or Yes No No
improvement, and the reduction of motor fluctuations was still
leukoencephalopathy
Previous major abdominal surgery No No Yes relevant (65.8%).13
Peripheral neuropathy No No Yes/No
No caregiver support Yes/No Yes Yes Procedure
The following description is based on the experience of the
Grenoble team but the steps and the operative technique may vary
three procedures, and the role of nursing in patient management according to the clinical setting and the experience of surgical
(Table 2). staff.14 The withdrawal of antiparkinsonian medications at least
12 h prior to the DBS procedure is recommended. The STN target is
Deep brain stimulation visualized and established by brain stereotactic MRI.14 Microelec-
trodes are introduced stereotactically into the STN and electro-
In the 80s, Benabid and coworkers showed that thalamus physiological assessment is performed to localize the target more
“stimulation” by an electrode implanted in the brain and connected easily. Patients undergo this procedure under local anesthesia, in
to a high-frequency stimulator localized in a thoracic subcutaneous order that the neurologist may immediately evaluate the motor
pocket was as efficient at reducing the tremor as lesional pro- benefit and possible side effects resulting from stimulation. How-
cedures.7 Over time, the globus pallidus internus (GPi) and the ever, general anesthesia may be used to decrease the stress and
subthalamic nucleus (STN) were found to be more effective targets pain for the patient. When the ideal localization has been identi-
than the thalamus in controlling the main signs of PD, such as fied, the microelectrodes are removed and two chronic leads with
rigidity and bradykinesia, in addition to tremor. The DBS clinical four contacts each are placed on and fixed to the skull. Immediately
effect consists of a motor symptom improvement similar to that after, or a few days later, the leads are connected to a stimulator
obtained with supra-maximal doses of levodopa, but with better which is implanted under general anesthesia in a subcutaneous
control of motor fluctuations and dyskinesias.8 pocket in the subclavicular area (Fig. 1A).14
The mechanism of action of DBS is unclear and widely debated. Programming of the best stimulation parameters usually lasts
It has been hypothesized that the stimulation exerts an inhibitory for several weeks and requires accurate and extensive work by
synaptic effect and regulates the electric and biochemical activity of neurologists trained in PD pharmacological management, and both
the cells in the basal ganglia, modifies the firing rate and pattern of technical aspects and possible complications of DBS. The optimal
the neuronal pool and suppresses the abnormal rhythmic oscilla- stimulation is obtained when the selected parameters and contacts
tion between the cortex and the basal ganglia.9 These changes are induce the best control of motor symptoms and complications, and
able to modify local neurotransmitter release and increase brain the lowest occurrence of side effects. The optimization of stimula-
blood flow and neurogenesis.9 tion requires some months, with a progressive reduction of

Table 2
Adverse events, complications, costs and nursing role related to deep brain stimulation (DBS), continuous subcutaneous infusion of apomorphine (CSAI) and levodopa/
carbidopa intestinal gel (LCIG) infusion.

Side effects Procedure Device complications Costa Nursing role

DBS Cognitive dysfunction, mood disorders,
axial signs worsening
CSAI Nausea, vomiting, postural hypotension,
bradycardia, subcutaneous nodules,
neuropsychiatric disorders
LCIG Duodenal ulcer, secretion from the stoma,
infusion granuloma, abdominal pain, transient or persistent
infections of ostomy, intestinal occlusion,
peripheral neuropathy
a
Mean cumulative 5 year cost per patient.6
complications
Intracranial Skin erosion, infection, lead fracture V 88,014 Patients selection, preoperative and
hemorrhage or migration $ 97,149 intraoperative physical and psychological
support, parameter programming,
evaluation of side effects
None Malfunction, occlusion V 141,393 Patients selection, assisting the neurologist
significant $ 156,069 during the challenge test and continuous
infusion, training of caregivers about skin
hygiene rules, performing subcutaneous
injections, management of subcutaneous
nodules
Surgical risk Pump malfunctioning, occlusion, V 233,986 Patients selection, pump management,
disconnection, kinking, jejunal $ 258,273 ostomy dressing, weight monitoring
incarceration, tube leakage
436 A. De Rosa et al. / Geriatric Nursing 37 (2016) 434e439

Fig. 1. A) Deep Brain Stimulation: the two electrodes placed in the basal ganglia are fixed to the skull and connected to a stimulator implanted in a subcutaneous pocket in the
subclavicular area (https://www.tga.gov.au/alert/medtronic-deep-brain-stimulation-and-spinal-cord-stimulation-devices-multiple-models). B) Pump for subcutaneous apomor-
phine infusion is connected to a needle inserted in the skin of the abdominal wall.* (http://www.hopeparkinson.org/uploads/pagesfiles/404.pdf). C) The pump containing levodopa-
carbidopa gel (Duodopa) is connected to the distal duodenum and jejunum via a small tube placed through a percutaneous endoscopic gastrostomy/jejunostomy (PEG/J).* (http://
www.epda.eu.com/EasySiteWeb/GatewayLink.aspx?alId¼16254). *The pumps are lightweight and the patients can easily wear them using a shoulder strap.

dopaminergic treatment.15 See Refs. 14 and 15 for a more detailed
description of the parameter settings.
Patient selection
The CAPSIT-PD protocol has been constituted in order to
determine the steps for selection, preoperative evaluation and
post-operative follow-up of candidate patients for DBS.16 Levodopa
responsiveness represents the best predictor of procedure effi-
ciency. Therefore, patients presenting symptoms mainly resistant
to levodopa, such as postural instability, speech and gait disorders,
should be not eligible for DBS, which may progressively worsen
axial signs. Concerning age, to date there is not sufficient evidence
to establish a definite limit, but some authors suggest a cut-off of 75
years, because procedure efficacy and safety have not been suffi-
ciently studied above that age.17 Although DBS has usually been
reserved for patients in advanced stages of the disease, the findings
of a recent multicentre randomized trial, the EARLYSTIM trial,
showed that STN-DBS performed early in the disease course (mean
disease duration 7.5 years, with motor fluctuations for <3 years)
improved patients’ quality of life and several secondary outcome
measures more than the best medical therapy.18
The disease duration recommended by the CAPSIT-PD protocol
should be at least 5 years, in order to avoid the risk of including
patients with levodopa-responsive atypical Parkinsonism. Cogni-
tive impairment represents a contraindication for STN-DBS surgery,
which has been reported to cause a worsening in verbal fluency and
frontal-executive functions (Table 1).19,20 A systematic assessment
for psychiatric symptoms should be performed before the inter-
vention in order to exclude severe depression,21 primary psychotic
disorders, uncompensated bipolar disorders and substance abuse.
Severe diseases, such as unstable heart disease, serious infections,
advanced renal or hepatic failure, or malignancy, represent a
contraindication since they may compromise DBS benefits, increase
post-surgery complications and reduce life expectancy.11,17
Screening assessment includes a brain MRI to exclude the pres-
ence of structural lesions, severe atrophy, leukoencephalopathy or
multiple ischemic lacunae, which represent exclusion criteria for
surgery.17
Adverse events
The most serious early complications related to the surgical
procedure are intracranial hemorrhage (1% reported by the
Grenoble group), even though the occurrence of permanent
disability is low, and seizures.14,22,23 After surgery, aspiration
pneumonia, transient post-operative confusion, delirium and psy-
chosis have been observed, also due to the preoperative withdrawal
of dopaminergic drugs.14,22
The most frequent hardware-related complications include skin
erosion (1e2.5%), infections (4%), caused by Staphylococcus aureus
in 40e60% of cases, lead fracture (3.0%) or migration (2.4%).14,22
The stimulation-related side effects are usually due to diffusion
of current to the surrounding nervous structures or suboptimal
placement of the electrodes, and consist of tetanic contractions,
dysarthria, paresthesias, double and blurred vision, eyelid-opening
apraxia, and weight gain.23 These effects are usually controlled by
parameters or drug dose adjustment, selection of a contact with
fewer side effects, or passage to a bipolar modality, which allows
stimulation restricted on the target and limits diffusion to adjacent
structures. Other events such as mydriasis, flushing, sweating and
gaze deviation are transient, developing habituation with various
latencies (from seconds to weeks).11 Dyskinesia represents an early
side effect but usually undergoes habituation; it suggests a correct
placement of the electrode and may be overcome by decreasing the
dopaminergic treatment dosage. As mentioned above, STN-DBS
may worsen mood disorders,9,21 cognitive abilities, in particular
executive functions and verbal fluency, and axial signs, such as
speech, gait and balance abnormalities.24,25
The role of nursing
Nursing staff should be familiar with the inclusion criteria for
DBS. In the preoperative phase, it should collaborate with the
medical team in selecting the candidate patients for DBS and
providing adequate and comprehensive information about multi-
disciplinary assessments (e.g., neurosurgical, psychiatric, neuro-
psychological, physiatric, nutritional), procedural steps, hospital
stay time and possible post-operative complications. A nurse
should support and establish a trust relationship with patients and
their relatives, ensuring that they have understood the information
given by the neurologist and neurosurgeon and possibly clarify any
questions.26,27
During the hospitalization period, the nursing staff is essential
in order to keep the medical team updated about motor fluctua-
tions and non-motor symptoms, such as pain, sleep, constipation
and urinary disorders. The role of nursing is highly important in the
 A. De Rosa et al. / Geriatric Nursing 37 (2016) 434e439
preoperative and intraoperative period when the patient is in “off”
condition due to drug discontinuation, and needs particular phys-
ical and psychological support. Since the implantation can last
several hours, the operating room nurse should be sensitive to the
patients’ various needs, chiefly when they are conscious. Special
attention should be paid to sensations of cold or pain caused by the
prolonged uncomfortable position, or discomfort due to the “off”
condition, side effects due to stimulation, such as dyskinesias,
paresthesias, diplopia, tetanic contractions.
During the post-operative period, the nurse supports the
neurologist in parameter programming, evaluating the effective-
ness of stimulation and reporting adverse events promptly.28 After
discharge, the nurse should periodically phone or visit the patients
at home in order to monitor the effects of stimulation, side effects
such as skin infections and erosions, referring them to the medical
team, and anticipating follow-up visits, if necessary.
Continuous subcutaneous apomorphine infusion
The antiparkinsonian properties of apomorphine were shown
by Schwab and colleagues in 1951.29 Apomorphine is a dopami-
nergic agonist which exerts its effect through direct stimulation of
striatal postsynaptic dopamine D1 and D2 receptors. The absorp-
tion of subcutaneously injected apomorphine is rapid, bioavail-
ability is nearly 100%, and its half-life is short (about 43 min). Its
highly lipophilic nature allows fast transit to the central nervous
system and explains the fast onset of the clinical response. The
motor effect appears within 5e15 min after administration and
depends on local factors, such as injection site (the abdominal wall
is preferable to the thigh), skin temperature, and subcutaneous
tissue thickness.30 Apomorphine may be administered as inter-
mittent subcutaneous bolus to treat predictable or sudden “off”
state, or as daily continuous infusion in cases of non-responsive
motor complications.
A consistent improvement in “off” time with a decrement be-
tween 50 and 80% has been reported by clinical studies on CSAI.
This treatment is not yet available in the U.S.A., where apomor-
phine is currently approved only for intermittent subcutaneous
administration. In recent years, other promising administration
systems have been considered through the delivery of intravenous,
oral, nasal, sublingual and rectal formulations.31,32 In a 12-year
follow-up study which compared clinical and neuropsychological
effects of STN-DBS and CSAI, both were effective on off-time
reduction (76% vs 51%) and daily levodopa dose reduction (62% vs
29%), whereas dyskinesias decreased by 81% among subjects un-
dergoing STN-DBS and did not change among those treated by
CSAI.33 On the other hand, CSAI did not cause cognitive and psy-
chiatric dysfunctions compared with DBS.34 Moreover, CSAI did not
worsen dopa-resistant motor axial symptoms such as postural
instability and gait disorders, which may occur or worsen after
STN-DBS.35
Procedure
Before beginning CSAI, all dopamine agonists should be dis-
continued overnight. Levodopa may be withdrawn, or kept at the
same dosage only in the morning and evening. Premedication with
domperidone should be started one day before the infusion at a
dose of 10 mg up to three times a day in order to avoid potential
adverse events, such as vomiting and hypotension.36 Domperidone
administration should not normally be prolonged more than one
week so as to avoid cardiovascular side effects such as QT prolon-
gation and arrhythmias.36 Apomorphine is delivered by an appro-
priate pump connected to a needle inserted in the skin of the
abdominal wall (Fig. 1B). The initial dosage is 1 mg/h, increasing by
0.5 mg/h every 2e4 h, depending on tolerability and clinical
437
benefit.37,38 The infusion may be prolonged for 16 h in daytime only
and should be discontinued at night.36 The daily average dosage is
4e7 mg/h.36
Patient selection
Patients with contraindications to STN-DBS, such as moderate
cognitive impairment, levodopa-unresponsive axial symptoms,
speech disorders, and severe mood disorders may be candidates for
CSAI. This treatment should be not considered for subjects of
advanced age, lacking social or familial support, or affected by
severe dementia or psychosis, orthostatic hypotension, systemic
disease (hepatic, renal or cardiac failure).39 Caution is required for
patients affected by diabetes or presenting cellulitis or other skin
diseases.
Adverse events
Nausea, vomiting, and cardiovascular events, such as brady-
cardia and postural hypotension may be avoided by premedication
and co-administration of domperidone. Other effects induced by
peripheral vasodilatation are flushing, sweating, rhinorrhea and
lacrimation.30 Neuropsychiatric events such as confusion, halluci-
nations, psychosis, impulse control disorders, sedation, and sleep
attacks may be observed as with other dopamine agonists. Subcu-
taneous nodules are dose-related and develop in most patients
(70% incidence) after long-term therapy with CSAI, but rarely lead
to drug discontinuation.38
Hematologic effects are benign transient eosinophilia, positive
Coombs direct test and, in a few patients, hemolytic anemia. They
require a hematologic follow-up but rarely drug withdrawal.30
The role of nursing
The success of CSAI depends on good patient compliance, con-
stant support by caregivers, periodic nursing assessment (also at
patients’ homes), and long-term medical follow-up. The nurse
should be able to identify patients who could benefit from this
treatment. Furthermore, the nurse is critical in order to establish
efficient communication with the patients and relatives, and within
the multidisciplinary team. The management of the device requires
the assistance of a trained team of nurses, capable of handling
technical problems (i.e. malfunction, occlusion) and detecting any
local skin complications. During the hospital stay, the nurse should
assist the neurologist during the apomorphine challenge test and
the continuous infusion in order to monitor the drug effectiveness
and possible side effects, such as hypotension, vomiting and hal-
lucinations, and support the patient in coping with the physical and
psychological discomfort due to the reduction or discontinuation of
oral dopaminergic drugs.
Before discharge from hospital, the nursing staff should train the
patients and/or their family members in the use of the pump and
instruct them on correct skin disinfection and prompt recognition
of side effects. It is fundamental that the nurse is sure that the
patient or caregiver is actually independent in carrying out these
tasks. The nurse may suggest several strategies to prevent or
minimize skin reactions such as a daily change of injection site with
round-the-clock administration, avoiding the periumbilical area,
following asepsis and skin hygiene rules, using 29 Gauge soft and
fine needles with a 30 cm Teflon cannula and a luer lock connector,
performing deep injections, covering the needle by silicone
patches, and massaging the needle insertion site after the daily
infusion.31 In particular, massages with tea tree oil seem to reduce
tissue irritation and inflammation.40 The management of subcu-
taneous nodules varies depending on the type and severity of the
disorder. Topical corticosteroid and fibrinolytic use and low-
frequency ultrasound are recommended for treating mild or
fibrous nodules. Infection and necrosis, which are exceptional,
438 A. De Rosa et al. / Geriatric Nursing 37 (2016) 434e439
require antibiotics, surgical drainage or excision and usually
determine definitive treatment discontinuation.
Duodenal levodopa infusion
The introduction of levodopa infusion into the duodenum
allows the bypassing of unpredictable oral absorption due to
erratic, delayed and incomplete gastric emptying, resulting in less
variable plasma concentrations of the drug and continuous, more
physiological, dopaminergic stimulation. As the low water-
solubility of levodopa required large solution volumes, a methyl-
cellulose gel suspension of micronized levodopa (20 mg/ml) and
carbidopa (5 mg/ml) (Duodopa) was recently developed and is now
available in several countries.41
LCIG is directly delivered inside the distal duodenum and
jejunum via a small tube placed through a percutaneous endo-
scopic gastrostomy/jejunostomy (PEG/J) for permanent use
(Fig. 1C).42e44 LCIG is available in cassettes attached to a portable
programmable pump connected to the PEG/J. A standard cassette
contains 100 ml of gel, providing up to 2000 mg of levodopa.
Several short-term non-blind trials have demonstrated that
enteral infusional treatment improves motor fluctuations, reducing
the “on” time up to several hours in comparison to oral levodopa
administration.43 Some studies in advanced PD patients with a
follow-up ranging between 6 and 24 months showed significant
improvement in motor complications associated with a progressive
reduction of disabling dyskinesias.44e46
One of the main limitations of this therapy is that it is highly
expensive.6
Procedure
The evaluation prior to implantation, the PEG/J location and
the follow-up, require the involvement, constant communication
and cooperation within a multidisciplinary team consisting of a
neurologist, a gastroenterologist endoscopist, an experienced nurse
and a dietician. Gastroenterological assessment is necessary in or-
der to exclude previous gastrointestinal diseases or surgery.
Gastroscopy with biopsy is performed so as to detect Helicobacter
Pilory (HP) infection. Serum vitamin B12, folic acid, metylmalonic
acid and homocysteine levels are evaluated, and motor and sensory
nerve conduction studies are usually performed in order to detect
the presence of a pre-existing peripheral neuropathy, which may be
worsened or caused by LCIG treatment. A 3e4 days test with a
nasoduodenal intestinal tube is performed so as to assess the
clinical effect on motor symptoms and fluctuations, the tolerability
and compliance of the patients, and to adjust the dose.47
If a good response is observed, the nasoduodenal tube is
removed and the PEG/J is positioned under local anesthesia with
the aid of a gastroscopy, which is useful for establishing the
appropriate site. Prophylactic antibiotic therapy is administered
after implantation so as to prevent peristomal skin infections. The
assessment of the correct positioning of the PEG/J is carried out by
performing an abdomen X-ray. If the procedure is conducted
properly, the infusion is started after the discontinuation of other
antiparkinsonian drugs. Usually, the pump is connected in the
morning, giving a bolus starting dose between 2.5 and 7 ml.48 The
mean daily maintenance dose is calculated according to the pre-
vious oral dose and detracting the morning dose, and ranges be-
tween 2.4 and 5 ml/h (48e100 mg/h of levodopa). Extra bolus doses
between 0.5 and 2 ml may be required if an off-state occurs during
the day.48
Duodopa is usually administered in monotherapy, but, if
necessary, other antiparkinsonian drugs may be added. Gastros-
copy should be repeated and the PEG/J evaluated for possible
replacement each year.
Patient selection
According to a proposed algorithm for patient selection, LCIG
treatment is recommended in PD subjects who are levodopa-
responsive but with insufficient control of motor fluctuations and
dyskinesias, despite optimal oral/transdermal therapy.37 Elderly
patients without severe cognitive decline and/or severe dopami-
nergic psychosis may be contemplated for LCIG.39 Patients with
mild or moderate depression and anxiety may be considered.
Severe coagulopathy, previous gastrectomy, gastroenteroana-
stomosis or other abdominal surgery, and ascites represent a
contraindication.49 A pre-existent peripheral neuropathy should be
carefully checked and the risk/benefit ratio taken into account. The
availability of reliable caregivers and the patients’ ability to manage
the pump, tolerate the surgical procedure and the pump weight are
essential.
Adverse events
Beyond the typical side effects caused by levodopa therapy, such
as psychosis, confusion, somnolence and dyskinesias, the more
frequent adverse events are related to the device and the surgical
procedure. Possible complications related to the PEG/J are perito-
nitis, described in 4.5% of cases,50 duodenal ulcers, secretion from
the stoma, granuloma, abdominal pain, mild or severe, transient
or persistent stoma infections, and intestinal occlusions.46 A
frequently reported side effect is the accidental removal of the
PEG/J (55% of cases).46
An association between LCIG infusion and the development of a
subacute/chronic, mainly sensitive, axonal peripheral neuropathy
has been observed.51 This finding is associated with low vitamin
B12 and folic acid levels, and high homocysteine and methyl-
malonic acid levels, and may be due to malabsorption caused by the
levodopa gel formulation.52
The role of nursing
During the hospitalization state, the nurse should support the
patients during the test phase because they may be in “off” con-
dition, assist the neurologist in establishing the optimal therapeutic
dose of Duodopa, and monitor treatment response and side effects.
After the PEG/PEJ implantation, the nursing staff should take care of
the device management, cassette mounting, turning on and off the
pump, the administration of bolus doses according to the patient’s
symptoms, and cleaning the stoma. At the moment of discharge,
the nurse should educate and train the patients and their caregivers
in the management of the pump.
During the follow-up, the nurse should carefully monitor, reg-
ister any issues such as body weight loss or nausea (which may
suggest a device dislocation), and report possible serious side
effects to the center where the device has been implanted or to the
neurologist in charge of the patient. The timely detection and
management of local stomal complications, such as granuloma,
retraction, dermatitis, and abscess require nursing staff experi-
enced in wound care and enteral nutrition. The nursing team
should be trained in ostomy dressing and in preventing local
adverse events, ensuring correct hygiene and protecting the peri-
stomal skin. Furthermore, they should be able to classify the
complications (ulcerative, proliferative, erosive, and hyperemic),
establish what abdominal areas are involved, and choose and
perform the most suitable dressings for the lesion, such as hydro-
gel, hydrocolloids, alginate silver and polymeric membrane
dressings.
Conclusions
Each non conventional therapy for advanced PD proved to be
efficient and generally safe in managing motor fluctuations and
 A. De Rosa et al. / Geriatric Nursing 37 (2016) 434e439
dyskinesias, although, to date, DBS has shown a higher level of
evidence. A good outcome and a lower frequency of adverse events
strictly depend on correct candidate selection and careful assess-
ment of inclusion and exclusion criteria. Multidisciplinary
approach, long-term follow-up and constant support for the pa-
tients and caregivers are mandatory. After discharge, periodic
nursing visits at home should be ensured so as to monitor the
treatment’s effectiveness and adverse events, in particular for CSAI
and LCIG. The role of the nursing staff should not be limited to
medical care, but must also be intended to facilitate communica-
tion between patients and clinicians, interaction between different
care providers, and finally to support and educate patients and
caregivers.
Acknowledgments
The authors thank Josh Williams for checking the English of this
article.
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